NCLEX-PN
NCLEX Practice Test PN Questions
Extract:
Intake and output record
Time Oral intake Parenteral intake Output
0700 180 mL juice
0800 1 L 0.9% sodium chloride IV 150 mL liquid stool
1000 75 mL vancomycin
1200 240 mL tea 250 mL metronidazole IV
1500 360 mL water
1600 1300 mL urine from collection bag
Question 1 of 5
The nurse is calculating a client's intake and output for the shift. How many mL should the nurse record as the client's net fluid balance? Record your answer using a whole number.
Correct Answer: 655 mL
Rationale: 1. Intake:
Oral: 180 + 240 + 360 = 780 mL
IV: 1000 + 75 + 250 = 1325 mL
Total Intake = 780 + 1325 = 2105 mL
2. Output:
Stool: 150 mL
Urine: 1300 mL
Total Output = 1450 mL
3. Net Balance:
2105 − 1450 = 655 mL net positive balance
Extract:
Question 2 of 5
The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?
Correct Answer: A
Rationale: Black, tarry stool (melena) indicates upper gastrointestinal bleeding, a serious complication in cirrhosis due to portal hypertension or varices, requiring immediate intervention.
Question 3 of 5
The nurse is teaching an adult who has a broken ankle that has been casted how to climb stairs. The nurse knows that the client understands how to climb up stairs when she does which of the following?
Correct Answer: D
Rationale:
To climb stairs, weight is borne on crutches, moving the unaffected leg first, then the affected leg and crutches, ensuring stability and safety using the stronger leg.
Question 4 of 5
A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for reinforcement of teaching?
Correct Answer: D
Rationale: Placing full weight on the surgical leg when going down stairs risks injury and instability. The client should lead with the cane and unaffected leg, using the surgical leg cautiously.
Question 5 of 5
The nurse in the outpatient clinic is talking with the spouse of a client with borderline personality disorder. The client's spouse states, 'My spouse self-inflicts lacerations on the arms to stop me from traveling for business. My spouse's actions are not a serious attempt at self-harm.' Which of the following responses would be appropriate for the nurse to make?
Correct Answer: B
Rationale: Self-inflicted lacerations, even if not suicidal, indicate significant distress in borderline personality disorder and require professional assessment to ensure safety and address underlying issues.